橈骨小頭半脫位

.,橈骨頭半脫位,邢臺縣醫(yī)院骨科許湞鋮,.,Whats橈骨頭半脫位？,.,專業(yè)回答,牽拉肘，也被稱作環(huán)狀韌帶移位或橈骨頭半脫位，是兒童常見的骨科損傷。IntheUnitedStates,theincidenceofemergencydepartmentvisitsforpulledelbowisestimatedat2.7per1000personsyoungerthan18yearsofage.Themedianageatpresentationis2years.在美國，未成年人急診就診中牽拉肘的發(fā)生率大約在2.7/1000.相關(guān)報道的中位年齡為2歲。Theinjuryisuniquetoinfantsandyoungchildrenbecausetheradialheadislessbulbousthanitisinolderpersonsandmayeasilybecomedisplaced.牽拉肘特別常見于嬰幼兒和青少年，因為幼兒的橈骨頭還未發(fā)育像成人那樣的圓球狀橈骨頭，所以很容易移位。Reductionofapulledelbowisasafeprocedurethatcanbeperformedintheoutpatientsetting.復(fù)位牽拉肘是相對安全的操作，完全可以在門診進行。Theannularligamentencirclestheneckoftheradiusandholdsittightlyinplaceagainsttheulna),therebymaintainingthepositionoftheproximalradiusinrelationtotheulnaandthecapitellumofthedistalhumeruswhileallowing180-degreerotation.環(huán)狀韌帶包繞橈骨頸使其緊鄰尺骨，從而維持橈骨與毗鄰尺骨以及肱骨遠端肱骨小頭的相對位置，同時可以完成180旋轉(zhuǎn)。Whenthereisforcefullongitudinaltraction,suchaswhenachildispulledorliftedbythearm,theradialheadispulledunderneaththeannularligament.在強大的縱向（軸向）牽拉下，比如提拉幼兒手臂或用手臂引體向上時，橈骨頭會被牽拉至環(huán)狀韌帶下方。,.,大多數(shù)孩子的病史中可能有過被牽拉的情況,.,.,環(huán)狀韌帶嵌壓的環(huán)狀韌帶,環(huán)狀韌帶包繞橈骨頸，并維持橈骨緊鄰尺骨,軸向牽拉時，橈骨頭包埋在環(huán)狀韌帶下,.,首先，明確孩子的病史及體檢與診斷一致。Thechildshistorymayincludeawitnessedeventofforcefultraction;however,othermechanismsofinjuryhavealsobeendescribed.孩子的病史中可能有過被牽拉的情況；然而，其它的損失機制也有描述過。Physicalexaminationshouldrevealpseudoparalysis,withthechildvoluntarilykeepingthelimbstilltominimizediscomfort.體格檢查會發(fā)現(xiàn)假性神經(jīng)麻痹，而孩子為了減少不適會自主保持上肢制動。Therewillalsobepainwithmovement,mostoftenrelatedtosupinationandpronationratherthantoflexionandextension.活動時疼痛，旋前或旋后較屈伸更易產(chǎn)生。Inmostcasestherewillbetendernesstopalpationonthelateralsideoftheelbow;however,absenceofthistendernessdoesnotruleoutthediagnosis.多數(shù)情況下觸診肘關(guān)節(jié)外側(cè)可及虛空感，即使未及虛空感也不能排除該診斷。Anaffectedchildholdstheelbowinaslightlyflexedposition,withthehandpronated.受傷的孩童將被迫保持肘關(guān)節(jié)輕微屈曲位并維持手掌旋前位。Furtherexaminationshouldalsorevealanormal-lookingelbowwithouteffusion,bruising,orobviousdeformity.更進一步的檢查則會發(fā)現(xiàn)肘關(guān)節(jié)外形正常，無突出，無挫傷或明顯的畸形。Radiographsarealmostalwaysnormalincasesofpulledelbow,soradiographyshouldbereservedforcasesinwhichthediagnosisisnotclear.,.,牽拉肘的影像學(xué)檢查幾乎都是正常的，所以只有在診斷不明確時才考慮進行影像學(xué)檢查。However,positioningtheelbowinpreparationforradiographyisoftentherapeuticinreducingthedisplacement.然而，在放置體位來進行影像學(xué)檢查時，往往對復(fù)位移位有幫助。Contraindications禁忌征ThecontraindicationstoperformingareductionarefewandareusuallyeasilyRecognized.復(fù)位的禁忌征很少且容易鑒別。Ifachildhasahistoryandphysicalexaminationthatareconsistentwithfracture,suchasdeformity,swelling,orbruisingoftheelboworahistoryofafallontothearmfromasubstantialheight,thenaradiographshouldbeobtainedtoevaluateforfracture.如果孩子的病史或體格檢查與骨折吻合，比如畸形，腫脹或肘關(guān)節(jié)挫傷或有高處摔落手臂著地的外傷史，則應(yīng)行影像學(xué)檢查來判斷是否骨折。Iftheradiographdoesnotrevealfractureoreffusion,thenreductionmaybeconsidered.如果影像學(xué)檢查未發(fā)現(xiàn)骨折或突出，則可以考慮手法復(fù)位。,.,Inonestudy,reductionwasachievedonthefirstattemptin95%ofpatientswhounderwentrandomizationtohyperpronationascomparedwith77%ofpatientswhounderwentrandomizationtosupination.在一項研究中，隨機予以過度旋前手法首次復(fù)位成功的比例是95%，而旋后手法則為77%。SupinationTechnique旋后手法Toperformthesupinationtechnique,seatthechildontheparentorcaregiverslap,withthechildfacingyou.Claspboththehandandelbowoftheaffectedarm(圖.3).采用旋后手法時，讓孩子坐在家長或監(jiān)護人的大腿上面對著操作者?？圩』贾氖趾椭狻ourfingersorthumbshouldoverlietheradialhead.Neitherthepositioningofyourfingersorthumbnorthestartingpositionoftheaffectedarmiscriticaltothesuccessoftheprocedure.操作者的手指后大拇指應(yīng)壓在橈骨頭上。無論是操作者的手指或大拇指位置或患肢的初始位置對于復(fù)位成功都至關(guān)重要。,.,Supinateandflextheforearmuntilyoufeeltheligamentmovebackintoposition(圖.4).Youmayfeelorhearaclickastheligamentisreduced.旋前屈曲前臂直到感覺環(huán)狀韌帶移回至正常位置。環(huán)狀韌帶復(fù)位時操作者可以感覺或聽到輕微的咔噠聲。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletoreachforanobjectabovethehead.如果復(fù)位成功，孩子便會不痛并能在5-30分鐘內(nèi)自如活動，包括碰觸高過頭頂?shù)奈矬w。HyperpronationTechnique過度旋前法Hyperpronationcanbetheprimarymethodusedtoreduceapulledelbow,oritcanbeusedifthesupinationtechniquehasfailed.Seatthechildontheparentsorcaregiverslap,withthechildfacingyou.However,ifanyotherabnormalitiesarepresent,suchasevidenceofinfection,reductionshouldnotbeattemptedandimmediateevaluationofthecauseandappropriatetreatmentshouldbeinitiated.但是，如果合并其它任何疾病，比如感染，則不能予以復(fù)位而應(yīng)立即評估造成疾病的原因同時立即予以適當(dāng)?shù)闹委煛?.,Preparation準(zhǔn)備Noequipmentisrequiredforthereductionofapulledelbow.Theclinicianshandsshouldbewashedthoroughlyaspartofstandardprecautions.復(fù)位肘關(guān)節(jié)無需準(zhǔn)備任何設(shè)備。臨床醫(yī)生徹底洗手應(yīng)該是標(biāo)準(zhǔn)注意事項的一部分。Procedure操作Topreparetheparentorcaregiver,explainthatsomediscomfortmaybeassociatedwiththeprocedure.操作前告知家長或監(jiān)護人，操作過程中可能會造成一些不適。Thechildmaycryorscreamforseveralminutesaftertheradialheadhasbeenrelocatedtoitsproperposition.橈骨頭復(fù)位至正常位置后孩子可能會哭或喊叫一會。Twotechniquescanbeusedtocorrectapulledelbow.二種手法可以用來糾正牽拉肘。Thesupinationtechniquehastypicallybeenusedforreductionofpulledelbow;however,somestudiescomparingthesupinationwiththehyperpronationtechniquehaveshownthathyperpronationismoresuccessful.旋后法早已被用作為經(jīng)典的牽拉肘復(fù)位手法；然而，一些研究比較了旋后手法與過度旋前手法發(fā)現(xiàn)過度旋前法效果更好。,.,復(fù)位肘關(guān)節(jié)可以首選過度旋前法或在旋后手法未能復(fù)位時再選擇過度旋前手法。讓孩子坐在家長或監(jiān)護人的大腿上，面對著操作者。Claspthehandoftheaffectedarmasyouwouldinahandshake(圖.5).Useyourfreehandtosupportthepatientselbow.握住患肢像握手那樣。用另一只手拖住患者的肘部。Hyperpronatethepatientswrist(圖.6).Youmayfeelorhearaclickastheligamentisreduced.旋前患者手腕。韌帶復(fù)位時可以感覺或聽到輕微的咔噠聲。Ifthereductionissuccessful,thechildshouldbepainfreeandabletomovethearmnormallyin5to30minutes,includingbeingabletolifttheaffectedarmabovethehead.如果復(fù)位成功，孩子便會不痛并能在5-30分鐘內(nèi)自如活動，包括碰觸高過頭頂?shù)奈矬w。Troubleshooting處理難題Mostreductionsofapulledelbowwillbesuccessfulafterasingleattempt.大多數(shù)的牽拉肘都能一次復(fù)位成功。,.,Ifaninitialattemptfails,theproceduremayberepeatedorthealternatetechniquemaybeused.如果初次復(fù)位失敗，可以再次嘗試復(fù)位或換一種復(fù)位手法。Iftheelbowhasnotbeenreducedafterthreeorfourattempts,reexaminethearmcarefullyfromshouldertofingertipsandobtainaradiographtoruleoutfracture.如果嘗試3-4次后仍無法復(fù)位肘關(guān)節(jié)，則應(yīng)再次仔細檢查從肩膀至手指并予以行影像學(xué)檢查來排除骨折。However,whenthecauseoftheinjuryordisplacementisafall,whenthecircumstancesoftheinjuryareunclear,orwhenitisdifficulttoperformathoroughexaminationbecausethechildisuncooperative,itisprudenttoobtainaradiographbeforethethirdorfourthattemptatreduction.然而，當(dāng)造成損傷或移位的原因是摔落，或損傷的周圍環(huán)境不清楚或則是因為孩子不配合而無法進行徹底的體格檢查時，在嘗試進行第三或第四次復(fù)位前為謹慎起見應(yīng)進行影像學(xué)檢查。Afterobtainingaradiograph,splinttheelbowatanangleofapproximately90degrees(evenifthechildpresentswiththearmmorefullyextended)andreferthechildtoanorthopedicsurgeon.影像學(xué)檢查后，用夾板固定肘關(guān)節(jié)在大約90的位置（即使孩子開始的手臂是過伸位的），然后將孩子轉(zhuǎn)診至骨科醫(yī)生。,.,Inthemajorityofsuchcases,theaffectedelbowwillreducespontaneouslyduringtheperiodofimmobilization.對于多數(shù)此類情況，受傷的肘關(guān)節(jié)會在制動期間自發(fā)復(fù)位。Aftercare操作后護理Whenapulledelbowhasbeensuccessf